Study on diagnosis and management strategies on heterotopic pregnancy: a retrospective study.

Heterotopic pregnancy (HP) is a rare but potentially life-threatening event with a high risk of maternal death, which also jeopardise the coexisting intrauterine pregnancy (IUP), thus an early accurate diagnosis and prompt treatment can decrease adverse complications. We aimed to explore the early predictors for pregnancy outcomes of HP. We reviewed patients with HP following assisted reproductive technology in our institution between January 2013 and December 2020. The relationships between pregnancy outcomes and clinical features were analysed by logistic regression. We found that 29 patients (72.5%) of HP were accurately diagnosed by transvaginal ultrasonography (TVS). Eighteen patients in the surgery group had live births, three of whom delivered preterm. Additionally, the miscarriage rate was lower for patients with IUP cardiac activity than those without (16.7% vs. 90.0%, p < .001). Further by logistic regression analysis, an IUP with cardiac activity at HP diagnosis was identified as favourable independent predictor of live birth (p < .001). Therefore, early diagnosis and prompt surgical intervention are recommended to prevent the development of HP.Impact of statementWhat is already known on this subject? Heterotopic pregnancy (HP) has long been thought to be a rare but potentially life-threatening event with a high risk of complications. The early diagnosis of HP is challenging due to the co-existence of a viable intrauterine pregnancy (IUP) and the absence of typical clinical symptoms.What do the results of this study add? This stduy showed that symptoms combined with routine transvaginal ultrasonography (TVS) scans reduce the rates of misdiagnosis of HP and prompt surgical intervention after diagnosis may minimise the incidence of miscarriage of the IUP.What are the implications of these findings for clinical practice and/or further research? An IUP with cardiac activity at HP diagnosis is a predictor of a favourable prognosis of HP, and laparoscopy under general anaesthesia is effective and safe during the first trimester of pregnancy. Awareness, assessment and early interventions in view of symptoms combined with routine TVS is recommended to reduce the risk of miscarriage and ensure a favourable live birth rate.

Ectopic pregnancy: a single-center experience over ten years.

PURPOSE: The aim of this study was to investigate characteristics associated with ectopic pregnancy (EP) that could be utilized for predicting morbidity or mortality. METHODS: This was a retrospective analysis of pregnancy-related records from a tertiary center over a period of ten years. Data on age, gravidity, parity, EP risk, amenorrhea duration, abdominal pain presence and location, ß-human chorionic gonadotropin (ß-HCG) level, ultrasound findings, therapeutic intervention, exact EP implantation site and length of hospital stay (LOS) were obtained from the database. The LOS was used as a proxy for morbidity and was tested for an association with all variables. All statistical analyses were conducted with Stata® (ver. 16.1, Texas, USA). RESULTS: The incidence of EP in a cohort of 30,247 pregnancies over a ten-year period was 1.05%. Patients presented with lower abdominal pain in 87.9% of cases, and the likelihood of experiencing pain was tenfold higher if fluid was detectable in the pouch of Douglas. Only 5.1% of patients had a detectable embryonic heartbeat, and 18.15% had one or more risk factors for EP. While most EPs were tubal, 2% were ovarian. The LOS was 1.9 days, and laparoscopic intervention was the main management procedure. The cohort included one genetically proven dizygotic heterotopic pregnancy (incidence, 3.3 × 10- 5) that was diagnosed in the 7th gestational week. The only association found was between the ß-HCG level and LOS, with a linear regression ß coefficient of 0.01 and a P-value of 0.04. CONCLUSION: EP is a relatively common condition affecting approximately 1% of all pregnancies. ß-HCG correlates with EP-related morbidity, but the overall morbidity rate of EP is low regardless of the implantation site. Laparoscopic surgery is an effective therapeutic procedure that is safe for managing EP, even in cases of heterotopic pregnancy.

Uterine Artery Embolization in the Twentieth Week of Pregnancy in Abnormally Invasive Placenta with Live Birth.

An abnormally invasive placenta is an increasing and potentially life-threatening pregnancy complication. The case presented herein is a heterotopic dichorial pregnancy with implantation of 1 placenta within the isthmocervical area, which caused vaginal bleeding during the 20th week of pregnancy, requiring a blood transfusion. To stop the bleeding, a bilateral embolization of the cervical branches of the uterine arteries was performed. The embolization was well tolerated and resulted in the abrupt and lasting cessation of bleeding for more than 10 weeks, resulting in the live birth of 1 child.

Heterotopic pregnancy: Simultaneous viable and nonviable pregnancies.

Heterotopic pregnancy occurs when a patient has simultaneous intrauterine and ectopic pregnancies. Rates of heterotopic pregnancy have been rising with increased availability and access to in vitro fertilization and other advanced fertility technologies. Symptoms of heterotopic pregnancy are nonspecific, such as vague abdominal pain, so transvaginal ultrasound is a crucial part of the diagnostic process. Laparoscopy is the most commonly performed treatment of the ectopic pregnancy; other options include localized injections of methotrexate and/or potassium chloride. Following definitive termination of the ectopic pregnancy, many patients will successfully deliver the intrauterine pregnancy at term. Early identification of heterotopic pregnancy can reduce maternal morbidity and mortality.

Successful heterotopic pregnancy with prior radical trachelectomy after transabdominal cervico isthimic cerclage with methotrexate treatment.

Heterotopic pregnancy with cervical incompetence is very uncommon. And yet there is no definite treatment for cervical incompetence occurring after radical trachelectomy. We are reporting a rare and novel case of a following in vitro fertilization combined intrauterine pregnancy and interstitial pregnancy which was successfully treated with maintenance of the pregnancy to term.

Heterotopic cervical pregnancy after in-vitro fertilization - case report and literature review.

Heterotopic cervical pregnancy is an uncommon condition, with a rising incidence due to the increasing number of pregnancies resulting from in-vitro fertilization (IVF). Although it is associated with maternal-fetal complications, there is no consensus in the literature about the best approach for this condition. This study aims to report a case of cervical heterotopic gestation after IVF in which the intrauterine pregnancy was preserved, with spontaneous elimination of the cervical gestational sac after patient sedation and introduction of the vaginal speculum. In addition, we reviewed the literature on the subject, which demonstrated that most cases have a favorable outcome, especially after treatment with surgical excision of the cervical pregnancy. The growing body of evidence is still scarce to define the best treatment for this condition.

Complications of Assisted Reproductive Technology.

Although only accounting for a small percentage of infants born in the United States each year, assisted reproductive technology (ART) has become a more common means of conception since the first in vitro fertilization baby was born in 1978. An understanding of the ART process, medications, and complications is becoming essential for emergency medicine practice. Much of the surveillance data focuses on ART complications that are likely to be less relevant in the acute care setting, but ovarian hyperstimulation syndrome, ectopic pregnancy, and ovarian torsion are 3 diagnoses with high potential morbidity and mortality that emergency physicians should not miss.

The effect of local aspiration and methotrexate injection on live interstitial pregnancy coexisting with live intrauterine pregnancy after assisted reproductive technology.

AIM: To share the experience of local aspiration and instillation of methotrexate (MTX) to selective reduction of live interstitial pregnancy and to evaluate its clinical effect and the outcome of intrauterine pregnancy. METHODS: Twelve patients with heterotopic interstitial pregnancy were enrolled at Women's Hospital, Zhejiang University School of Medicine, from 2006 to 2017. All the pregnancies were derived from assisted reproductive technology (ART). The transvaginal aspiration to interstitial pregnancy sac and local instillation of MTX (range from 12.5 to 30 mg) were performed for the patients under ultrasound-guide. The prognosis and pregnancy outcomes were followed up. RESULTS: No severe side effects of medical treatment were observed in all patients. Three cases underwent subsequent laparotomy cornual resection, and no perioperative complications were found in these three patients. Twelve patients gave birth to 13 healthy infants without congenital anomalies. The average birth weight and gestational age was 2837 g (SD ± 605 g) and 36.8 weeks (SD ± 2.4 weeks). No growth anomalies and mental retardation were observed in live birth offspring. CONCLUSION: The transvaginal ultrasound-guided aspiration and injection of MTX might be a feasible alternative treatment for heterotopic interstitial pregnancy when vital signs of patients are stable.

[Management and pregnancy outcomes of heterotopic pregnancy].

Objective: To investigate the clinical features, diagnosis and treatments of heterotopic pregnancy (HP) and demonstrate the outcomes of HP after the surgical treatment of ectopic pregnancies. Methods: A retrospective analysis was performed on 144 cases of HP in Women's Hospital, School of Medicine, Zhejiang University from January 2003 to December 2016. Results: (1) Clinical features of HP:the average age of patients was (30.8±3.8) years old, body mass index (BMI) was (21.9±2.9) kg/m(2), and was diagnosed at (6.5±1.3) weeks gestational age. Four patients (2.8%) were naturally pregnant, 10 patients (6.9%) received ovulation induction, and 130 patients (90.3%) had received infertility treatments. Fifty-one patients (35.4%) had no clinical symptoms, and 93 patients (64.6%) had clinical symptoms included vaginal hemorrhage,abdominal pain and hemorrhagic shock caused by intraperitoneal hemorrhage. The location of ectopic pregnancy was most common in the fallopian tubes (59.0%, 85/144) and the interstitial part (33.3%,48/144) . (2) Ectopic pregnancy treatment of HP:thirteen patients underwent expectation treatment, and the remaining 131 cases underwent surgical treatment, including laparoscopy (n=56) , laprotomy (n=52) , and fetal reduction (n=23) . Among the 131 patients underwent surgery, intrauterine pregnancy were found inevitable abortion in 6 cases preoperatively. The total early abortion rate after surgery was 14.4% (18/125) ; the second operation rate was 3.1% (4/131) . (3) Intrauterine pregnancy outcome of HP: 120 intrauterine fetal were survival, the total live birth rate was 83.3% (120/144) .One hundred and seven intrauterine fetal were survival after operation and the live birth rate after operation was 85.6% (107/125) . Twenty-nine cases were premature delivery and the premature delivery rate was 24.2% (29/120) . There was no significant differences between tubal HP and interstitial HP group in the preterm birth rate [25.8% (16/62) vs 26.3% (10/38) ; χ(2)=0.003, P>0.05]. Cesarean section rate of delivery in interstitial HP group was significantly higher than that in tubal HP group [97.4% (37/38) vs 59.7% (37/62) ], and the difference was statistically significant (χ(2)=17.400, P<0.05) . Conclusions: The clinical manifestations of HP are diversified, combining of high risk factors, clinical symptoms and ultrasonography could improve the accuracy of diagnosis. Different method has been used to treat HP, such as laparoscopic or laparotomy and fetal reduction, and there are varying degrees of failure rate and postoperative abortion rate. We should consider carefully to adopt expectant management. Through individualized treatment, most HP could get good perinatal outcomes.

The risk factors of miscarriage and obstetrical outcomes of intrauterine normal pregnancy following heterotopic pregnancy management.

To investigate the clinical characteristics and risk factors for miscarriage of intrauterine normal pregnancy of patients with a heterotopic pregnancy (HP) after treatment.This was a retrospective study of medical records from CHA Bundang Medical Center. Sixty-four patients who were diagnosed with a HP between February 2006 and July 2017 were included in this study. All analyses were performed using SAS software, version 9.4 (SAS Institute, Inc., Cary, NC). P values < .05 were considered statistically significant.Forty-eight patients had tubal ectopic pregnancies (EP), 10 patients had cornual EPs, 1 patient had a cesarean section scar EP, 4 patients had an ovarian EP, and 1 patient had bilateral tubal EP. Among the 64 patients, 14.1% (9/64) miscarried before 10 weeks of gestation after management. Mean gestational age (GA) at treatment was 5.97 ±â€Š0.50 weeks and 6.80 ±â€Š1.04 weeks for miscarriage and nonmiscarriage group, respectively (P = .008). Significant differences were observed between 2 groups in terms of ultrasonographic features at the time HP was diagnosed (P = .040) Logistic regression models indicated that gestational age at treatment showed significant differences between 2 groups (OR: 0.003, 95% CI: 0.001-0.604).Immediate management after diagnosis could expect favorable prognosis of HP. GA at treatment was the only independent risk factor for miscarriage in patients with HP regardless of treatment methods.

Normal vaginal delivery at term after expectant management of heterotopic caesarean scar pregnancy: a case report.

BACKGROUND: Heterotopic pregnancy with a combination of a caesarean scar pregnancy and an intrauterine pregnancy is rare and has potentially life-threatening complications. CASE PRESENTATION: We describe the case of a 27-year-old white woman who had experienced an emergency caesarean delivery at 39 weeks for fetal distress with no postpartum complications. This is a report of the successful expectant management of a heterotopic scar pregnancy. The gestational sac implanted into the scar area was non-viable. The woman was treated expectantly and had a normal vaginal delivery at 37 weeks of gestation. CONCLUSION: Expectant management under close monitoring can be appropriate in small non-viable heterotopic caesarean scar pregnancies.

Clinical analysis of 50 patients with heterotopic pregnancy after ovulation induction or embryo transfer.

OBJECTIVES: The purpose of this study was to evaluate the clinical characteristics, prenatal diagnosis, and management of patients with heterotopic pregnancy after ovulation induction or embryo transfer. METHODS: This was a retrospective study of fifty cases with heterotopic pregnancy, in which the fertilization way, type and number of embryo transferred, gestational age, clinical presentation and outcome of intrauterine, ultrasound presentation and site of ectopic pregnancy, bilateral fallopian tube and treatment were evaluated. RESULTS: Six patients had spontaneous pregnancy and two had artificial insemination after ovulation induction. Sixteen had fresh and nineteen had frozen embryo transfer with seven patients unrecorded its embryo type and number. The average days from transplantation (or intercourse/insemination) to diagnosing heterotopic pregnancy was thirty-seven with the earliest eighteen and the latest more than 70 days. Although the most common presentation was vaginal bleeding or abdominal pain, more than 21% was found by ultrasound and rare individuals even presented with gastrointestinal symptom which may imply ruptured EP and hemorrhagic shock. Giving proper treatment (surgery or local drug injection), the majority of them had a successful intrauterine pregnancy with only seven miscarried. CONCLUSIONS: Ovulation induction or embryo transfer increased the risk of HP greatly and clinician should raise high suspicious during the whole first trimester. Although the most ectopic site was ampullary, other sites such as cornual, cervical, abdominal especially interstitial or tubal stumps should also be assessed by ultrasound even in patients with bilateral salpingectomy or tubal obstructed. Repeated ultrasound tests 2 weeks after the diagnosis of intrauterine pregnancy with heart beating was very necessary to find the missed ones in suspicious patients. Compared with surgery, embryo suction with or without proper local drug injection would be more advisable for patients with cervical, cornual, or interstitial pregnancy in order to reserve the intrauterine pregnancy.

Effect of method of anesthesia on the reproductive and obstetric outcomes of heterotopic pregnancies.

BACKGROUND: Anesthesia is commonly used for surgical termination of the extrauterine component of heterotopic pregnancy. We sought to evaluate the effects of general and regional anesthesia during salpingectomy on reproductive and obstetric outcomes of heterotopic pregnancies. METHODS: A two-center, retrospective cohort study was conducted, and 49 heterotopic pregnancies were included. Baseline characteristics, reproductive and obstetric outcomes were compared between the general anesthesia and regional anesthesia groups. RESULTS: Baseline characteristics were comparable for age, weeks of gestation at diagnosis, and duration of anesthesia. No significant difference was found in pregnancy outcome, perinatal outcome or neonatal weight (P >0.05). The rate of miscarriage in the general anesthesia group was 23.5% versus the regional anesthesia group 15.6% (P >0.05). CONCLUSION: With respect to reproductive and obstetric outcomes, this retrospective study found no difference between general anesthesia and regional anesthesia used for early heterotopic pregnancy.

Embarazo heterotópico tubo-abdominal / Tube-Abdominal Heterotopic Pregnancy

El embarazo heterotópico es una rara gestación múltiple en donde un embarazo intrauterino coexiste con uno ectópico.La incidencia de embarazo heterotópico es de 1 cada 10 000 a 50 000 embarazos espontáneos. El aumento de los tratamientos por técnicas de reproducción asistida, ha incrementado la incidencia de embarazo heterotópico, ha llegado hasta 1 por ciento de los embarazos logrados por estas técnicas. El objetivo del trabajo es presentar el caso de una paciente con un embarazo heterotópico que resulta poco frecuente. Se presenta una paciente de 32 años, primípara, con antecedentes de salud que acudió por amenorrea de 10,2 semanas, dolor en bajo vientre con intensificación y sangramiento genital a manchas oscuras persistente. En el examen físico se constata un útero aumentado de tamaño que coincide con la amenorrea y el fondo de saco de Douglas abombado y doloroso. El examen ultrasonográfico fue concluyente en el diagnóstico de embarazo heterotópico. Se realizó una laparotomía y una salpingectomía total izquierda y exéresis de la placenta. El posoperatorio inmediato fue satisfactorio; el ultrasonido realizado tres semanas después, mostró la existencia de un embrión intrauterino de aproximadamente 12 semanas, vivo. La paciente fue seguida en consulta de Obstetricia y tuvo un parto eutócico a las 36,2 semanas con recién nacido vivo, en buen estado y bajo peso(AU)

Heterotopic pregnancy is a rare multiple pregnancy where an intrauterine pregnancy coexists with an ectopic pregnancy. The incidence of heterotopic pregnancy is 1 in 10,000 to 50,000 spontaneous pregnancies. The increase of assisted reproductive techniques has increased the incidence of heterotopic pregnancy, up to 1 % of the pregnancies achieved by these techniques. The objective of this study is to present the case of a patient with a heterotopic pregnancy that is rare. We present a 32-year-old female patient, primiparous, with a history of health. She came to consultation due to 10.2-week amenorrhea, low pain with intensification and genital persistent dark bleeding. The physical examination shows an enlarged uterus that coincides with amenorrhea and the plump and painful the bottom of Douglas sac. Ultrasonography was conclusive in the diagnosis of heterotopic pregnancy. A laparotomy and total left salpingectomy and excision of the placenta were performed. The immediate postoperative was satisfactory. The ultrasound performed three weeks later showed the existence of an intrauterine alive embryo of approximately 12 weeks. The patient was followed in consultation with obstetrics and she had a eutocic delivery at 36.2 weeks with alive newborn, in good condition and underweight(AU)

Hysteroscopic management of a heterotopic pregnancy following uterine artery embolization: a case report.

BACKGROUND: Intra-uterine pregnancy coexisting with cervical pregnancy (heterotopic pregnancy) is a rare condition and its management is challenging because of the massive bleeding associated with cervical pregnancy. Uterine artery embolization followed by hysteroscopic removal of cervical and intra-uterine products of conception can theoretically prevent massive bleeding and provide a direct view during the removal. Hysteroscopic management following uterine artery embolization of heterotopic pregnancy after in vitro fertilization and embryo transfer is rarely reported. CASE PRESENTATION: A 33-year-old primigravida, Asian, married, nonsmoker, nonalcoholic woman presented with heavy vaginal bleeding 3 weeks after in vitro fertilization and embryo transfer with a documented history of two embryo implantations in her uterine cavity. Transvaginal ultrasonography revealed a gestational sac of 15 mm × 9 mm × 9 mm with cardiac activity, showing a 3.0-mm-diameter yolk sac in the uterine cavity and a 15 mm × 11 mm × 8 mm gestational sac with cardiac activity, showing a 2.9-mm-diameter yolk sac in the cervical canal. The bilateral uterine artery embolization followed by hysteroscopic removal of both the gestational products was successfully performed after our patient and her family chose to give up the intra-uterine pregnancy due to the risk of heavy bleeding associated with cervical pregnancy. CONCLUSIONS: Uterine artery embolization followed by hysteroscopic removal of cervical and intra-uterine gestational products in the first trimester is safe and feasible, while preserving future fertility.

Management and outcome of 25 heterotopic pregnancies in Zhejiang, China.

OBJECTIVE: To characterize general attributes of women with heterotopic pregnancy (HP) in order to establish an optimal management regimen. STUDY DESIGN: A retrospective analysis was conducted on 25 HPs recorded at the Women's Hospital of Zhejiang University between 2007 and 2011. Data on patients' symptoms, risk factors, diagnostic features, treatment and outcome were collected and analysed. RESULTS: All patients had conceived via assisted reproductive technology (ART), 72% had a history of pelvic inflammatory disease and 68% of patients were symptomatic. Fifty-six percent of patients were diagnosed with HP via routine transvaginal ultrasound examination at approximately 6-7 weeks of gestation. Eighty percent of patients underwent surgical treatment (35% laparoscopic salpingectomy, 65% laparotomy), and 20% of patients underwent medical treatment with local injection of methotrexate (MTX) or MTX in combination with potassium chloride (KCl) into ectopic sites such as the cervix or interstitium. Eighty-eight percent of patients delivered live infants without congenital anomalies, and three patients (all of whom underwent surgical treatment) miscarried. CONCLUSIONS: Routine transvaginal ultrasound examination at approximately 6-7 weeks of gestation could facilitate the diagnosis of HP, although repeat ultrasound is necessary to avoid misdiagnosis. Prompt diagnosis and correct treatment, including local injection of MTX or MTX in combination with KCl into various ectopic sites, led to favourable prognoses.

Successful full-term twin deliveries in heterotopic cesarean scar pregnancy in a spontaneous cycle with expectant management.

Heterotopic cesarean scar pregnancy (CSP) usually follows assisted reproductive technologies (ART) in women who have already delivered by cesarean section. It is extremely rare: thus far, there have been only 12 individual case reports. However, over the last 20 years, the rate of cesarean delivery has increased and ART have become more common; hence, heterotopic CSP will be more prevalent in the future. Currently available data suggest that the early selective termination of CSP by medical or surgical methods is the most reliable treatment in the hemodynamically stable heterotopic CSP women because of the serious complications of continuing the CSP. We present the first case report of heterotopic CSP in a spontaneous cycle with expectant management that resulted in full-term twin deliveries.

Successful pregnancy in a woman with uterine scarring by transverse fundal cesarean section.

There has been only one case to date of pregnancy outcome after fundal transverse cesarean section (FTC). We report a pregnancy established after FTC. The FTC was performed at gestational week (GW) 24 in this patient's first pregnancy, but the uterus was preserved. Magnetic resonance imaging studies performed four times in her second pregnancy consistently showed part of the uterine fundus in which the muscle layer was interrupted. Concern regarding spontaneous uterine rupture in the absence of labor pains prompted us to interrupt her pregnancy at GW 31(+5) , delivering a premature, but otherwise healthy female infant, weighing 1832 g. The infant required transient intratracheal intubation for respiratory distress syndrome (for less than 1 h), but had an otherwise uneventful clinical course. Two cases, including ours, suggest that successful pregnancy outcome is feasible at least in some women with uterine scarring due to FTC.